Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, April 6, 2009

Rationing

A 97 year old guy was admitted recently to the trauma service following a fall, a face-plant actually, with a resultant broken nose and sinus fracture. Otherwise he was fine. He was 97 years old and he didn't take any medications, had never had surgery, and he lived independently in the same house he raised his kids in.

-How'd you fall, I asked.-Tripped over a rug or the carpet, he said. My cane snagged on something. I was visiting my wife.-Where was your wife?-The nursing home. I visit her as much as I can. It's not far.

His wife was 95 years old. Last year he had had to admit her to an assisted care facility because she "had got the dementia".

-Does she recognize you? I asked.-Yes. She remembers me. She remembers parts of our life together. -That's good, I said.-Yes, but she doesn't remember much else. She forgets things I told her even twenty minutes ago. And she remembers things that never happened. Like a third son. You see, we only had two boys, John and Richard. But she always talks about a third son. Always asks me how he's doing. Paul. She even has a name for him.

He looked out past me. There was a scabbed bandage across the bridge of his nose and he was bruised under his left eye. That day's NY Times was splayed out across his lap. A Teddy Roosevelt biography was bookmarked on his nightstand.

-That must be difficult for you, I said. He nodded.-My kids are all passed. I had a brother in Oklahoma but I don't know what happened to him. There's no one else. It's just me and Esther.-I'm sorry, I said.

I sat down in the chair next to his bed. It was a Friday afternoon. It was warm in the room and he was bundled up in several blankets. Some time passed and I absent-mindedly read the Times headlines upside down.

-She gets the dialysis three times a week, he said. Her kidney doctor told me last week that he didn't think the dialysis was doing any good. ...-I understand.-He wants me to think about stopping it. The dialysis.

I nodded. I leaned back in the chair. It was raining outside and windy and the thinner boughs of the trees bent in curved arcs with the wind. The old guy kept staring ahead, a blank TV screen.

-Anyway, I'll have to decide. I'll miss her. Even though she's not the same, I like going to see her. It's like when a baby smiles at you. It makes your day...

I sat there for a while. And then I had to go do some work. He went home the next morning but I've had a hard time forgetting him. I understand, as we move forward on health care reform, that rationing will play a larger and larger role. Given our technology and the rapid rate of innovation in health care, the amount of money we could conceivably spend on individual patients is infinite. At some point we will have to draw lines in the sand; enough is enough. I understand that. I've been an advocate for rationing myself, having experienced first-hand the wasted effort and financial drain of providing futile care to elderly patients in the ICU who aren't really "sick" but are actually just going through the dying process.

This case in particular is exemplary of an irrational health care expenditure. I mean seriously, hemodialysis on a 95 year old demented lady? It's crazy, right? Think of the money saved if we had a system in place that restricted or denied the possibility of nonegenarians receiving dialysis. No one in their right mind would disagree that the redistribution of resources from the provision of futile care to the elderly in order to make more preventative and life-saving care available for younger people is a solid moral stance. But then you see the consequences. These are real people who will have to be told "no more". When I drove home that night, a part of me was hoping that they'd keep that old guy's wife on dialysis just for a little while longer....

I enjoyed reading your story and looking over your blog for the first time. While interesting and thought-provoking, the story made me feel the gentleman was being rather selfish. Artificially extending his wife's life with dialysis instead of letting her be at peace? Just because we can does not always mean we should - would rationing actually help to make these choices easier for some?

Well posted. I would counter your chosen argument against rationing with a woman, whose husband was having everything done. He was gone. He was in the ICU, chilled, monitored. But gone. Thousands upon thousands.

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